Coverage Authorization List

Brand Namesort descending Generic Name Effective Date Requirements Class
Ibrance Palbociclib 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Oncology
Ibudone ibuprofen/hydrocodone 03/01/2018
  • Requires Prior Approval
  • Requires Step Therapy
  • Subject to Quantity Limits
Opioid Analgesics
Iclusig ponatinib tablets 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Oncology
Idelvion coagulation factor IX [recombinant], albumin fusion protein 01/01/2017
  • Requires Excluded Exception Approval
Hemophilia
Idhifa enasidenib 01/01/2018
  • Requires Excluded Exception Approval
Oncology
Ilaris canakinumab for subcutaneous [SC] injection 01/01/2017
  • Requires Prior Approval
Cryopyrin Associated Periodic Synd (CAPS)
Ilumya tildrakizumab-asmn 01/01/2019
  • Requires Prior Approval
Autoimmune
Imbruvica Ibrutinib 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Oncology
Imfinzi durvalumab 01/01/2018
  • Requires Excluded Exception Approval
Oncology
Imitrex sumatriptan tablets 01/01/2017
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine
Imlygic Talimogene Laherparepvec 01/01/2017
  • Requires Prior Approval
Oncology
Impoyz (Brand Only) clobestasol 01/01/2019
  • Requires Prior Approval
  • Subject to Quantity Limits
Corticosteroid
Inbrija levodopa inhalation powder 04/01/2019
  • Requires Prior Approval
  • Subject to Quantity Limits
Parkinson's Disease
Increlex mecasermin [rDNA origin] injection 01/01/2017
  • Requires Prior Approval
Growth Hormone and Related Disorders
Inflectra infliximab-dyyb 03/20/2020
  • Requires Excluded Exception Approval
Autoimmune
Ingrezza valbenazine 01/01/2018
  • Requires Excluded Exception Approval
Tardive Dyskinesia
Inlyta Axitinib 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Oncology
Inova benzoyl peroxide/salicylic acid pad 09/01/2017
  • Requires Prior Approval
  • Requires Step Therapy
Topical Acne Products
Inrebic fedratinib 10/01/2019
  • Requires Prior Approval
Oncology
Intelence etravirine 01/01/2018
  • Subject to Quantity Limits
HIV
Intermezzo zolpidem 01/01/2018
  • Requires Excluded Exception Approval
Sedative-Hypnotics
Intron A Interferon Alfa-2b 01/01/2017
  • Requires Prior Approval
Oncology
Invirase saquinavir 01/01/2018
  • Subject to Quantity Limits
HIV
Invokamet canagliflozin/metformin 01/01/2018
  • Requires Excluded Exception Approval
Diabetes
Invokana canagliflozin 01/01/2018
  • Requires Excluded Exception Approval
Diabetes
Iressa Gefitinib 01/01/2017
  • Requires Prior Approval
Oncology
Isentress raltegravir 01/01/2018
  • Subject to Quantity Limits
HIV
Istodax Romidepsin 01/01/2017
  • Requires Prior Approval
Oncology
Ixempra Ixabepilone 01/01/2017
  • Requires Prior Approval
Oncology
Ixinity Factor IX Concentrates 01/01/2017
  • Requires Prior Approval
Hemophilia
Jadenu deferasirox 01/01/2017
  • Requires Prior Approval
Iron Overload
Jakafi Ruxolitinib 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Oncology
Jatenzo testosterone undecanoate oral 01/01/2018
  • Requires Excluded Exception Approval
Testosterone Products
Jevtana Cabazitaxel 01/01/2017
  • Requires Prior Approval
Oncology
Jivi antihemophilic factor (recombinant) PEGylated-auci 01/01/2019
  • Requires Prior Approval
Hemophilia
Jornay PM methylphenidate extended-release 01/01/2019
  • Requires Prior Approval
  • Subject to Quantity Limits
ADHD-Narcolepsy Agents
Jublia efinaconazole topical solution 01/01/2017
  • Requires Prior Approval
Topical Antifungals
Juluca dolutegravir-rilpivirine 01/01/2018
  • Subject to Quantity Limits
HIV
Juxtapid lomitapide capsules 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Lipid Disorders
Jynarque tolvaptan 01/01/2019
  • Requires Prior Approval
Retinal Disorders
Kadcyla Ado-Trastuzumab emtansine 01/01/2017
  • Requires Prior Approval
Oncology
Kadian morphine sulfate ER capsules 03/01/2017
  • Requires Prior Approval
  • Requires Step Therapy
  • Subject to Quantity Limits
Opioid Analgesics - Extended-Release
Kalbitor Ecallantide 01/01/2017
  • Requires Prior Approval
Hereditary Angioedema
Kaletra lopinavir/ritonavir 01/01/2018
  • Subject to Quantity Limits
HIV
Kalydeco ivacaftor tablets 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Cystic Fibrosis
Kanjinti trastuzumab-anns 01/01/2017
  • Requires Prior Approval
Oncology
Kanuma Sebelipase alfa 01/01/2017
  • Requires Prior Approval
Lysosomal Storage Disorders
Kenalog (Brand Only) triamcinolone acetonide 01/01/2019
  • Requires Prior Approval
  • Subject to Quantity Limits
Corticosteroid
Kerydin tavaborole topical solution 01/01/2017
  • Requires Prior Approval
Topical Antifungals
Kesimpta ofatumumab 10/01/2020
  • Requires Prior Approval
Multiple Sclerosis